CLM-2026-030759
Meadow Imaging Center, Radiology. Service 2025-12-31 at outpatient hospital (POS 22). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Gregory Taylor
- Member ID
- UHC-40403-19
- Date of birth
- 1975-03-06
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-417881
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3545
- Coverage period
- 2025-10-01 to present
- Deductible
- $442.23 of $2,500.0018%
- Out-of-pocket maximum
- $4,120.67 of $10,000.0041%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4402940280
- Network
- In network
- Rendering NPI
- 4402940280
- Location
- San Diego, CA · TIN 30-5345877
- Authorisation / referral
- PA2025891118 / REF642304
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,339.00 | $1,286.45 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $454.00 | $249.70 | — | — | Review |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 25 | 1 | 2 | $2,111.00 | $1,161.05 | — | — | Review |
| Totals | $4,904.00 | $2,697.20 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- Patient account
- PA-339619
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000339 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-31: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025891118 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Meadow Imaging Center (4402940280). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for pain in right knee. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow Imaging Center2025-12-31 13:02
Patient seen for pain in right knee. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-02 05:40
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Prior auth letterPA2025891118_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-31 to 2026-03-31.
- Itemized billitemized_PA-339619.pdf7 pages
Itemised statement totalling $4904.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for pain in right knee. Note dictated; signature pending.”.
- AI recommendationPended2026-10-21 14:05The claim is pended due to incomplete documentation. The clinical note indicates that the patient was seen for pain in the right knee, but the note is pending a signature. A development letter has been sent to the provider to obtain the missing signature. Once the signature is obtained and the documentation is complete, the claim can be re-evaluated for approval.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 1087bd57
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021790 | 2026-06-05 | Desert Diagnostic Imaging | $2,023.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is pended due to incomplete documentation. The clinical note indicates that the patient was seen for pain in the right knee, but the note is pending a signature. A development letter has been sent to the provider to obtain the missing signature. Once the signature is obtained and the documentation is complete, the claim can be re-evaluated for approval.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.